Biomedical subjects

Patrick Heagerty

Publications and source records attributed to Patrick Heagerty.

14 recordsLinked to original sources

PubMed2006

Inflammatory response after influenza vaccination in men with and without carotid artery disease.

OBJECTIVE: Inflammatory markers are associated with vascular disease; however, variation in the acute phase response (APR) has not been evaluated. We evaluated whether the APR magnitude in men with severe carotid artery disease (CAAD) (>80% stenosis) differed from that of men without stenosis (<15% stenosis). METHODS AND RESULTS: White males with (n=43) and without (n=61) severe CAAD receiving clinical influenza vaccinations were recruited. Their baseline and 24-hour after -vaccination blood samples were assayed for C-reactive protein (CRP), IL-6, and serum amyloid-a (SAA). In vivo APR to vaccination was measurable and varied among subjects. Adjusted for age, smoking, oral hypoglycemics, aspirin, and stain use, the relative 24-hour changes in levels of ln(CRP), ln(IL-6), and ln(SAA) were higher in men with CAAD than in men without, but only the SAA response was significant (P=0.02); the relative SAA response was 1.6 (95% confidence interval, 1.1 to 2.5) times higher in men with than without CAAD. The APR for all markers appeared to be independent of baseline levels. CONCLUSIONS: Influenza vaccination results in a mild, but measurable, APR in men with and without CAAD. SAA APR variability may be a predictor of severe vascular disease that is independent of basal SAA level.

Acute-Phase Reaction↗

PubMed2005

Predicting time to subsequent pregnancy.

OBJECTIVES: Women in poverty may benefit from avoiding closely spaced pregnancies. This study sought to identify predictive factors that could identify women at risk for closely spaced pregnancies. METHODS: We studied 20,028 women receiving welfare (cash assistance) from Washington State. Using Cox proportional hazards methods, we estimated the effects of individual- and community-level variables on time from an index birth until a subsequent pregnancy (between June 1992 and December 1999). Prediction models developed in a random half of our data were validated in the other half. Receiver operator characteristic plots appropriate for proportional hazards models were calculated to compare the sensitivity and specificity of each model. RESULTS: At 5 years of follow-up, the most predictive model contained just individual-level variables (age, education, race, marital status, number of prior pregnancies); the area under the receiver operator characteristic curve was 0.66 (.62-.69). The addition of community-level variables (percent in poverty, with a high school degree or higher, Black, Hispanic, in an urban area; female unemployment rate; income inequality) added little predictive ability. Differences were found between women with different individual- and community-level characteristics, but the results suggest that these factors are not strong predictors of pregnancy spacing. CONCLUSIONS: Individual- and community-level characteristics are associated with interpregnancy intervals; however, we found little evidence that the selected variables predicted pregnancy interval in a useful manner.

Adolescent↗

PubMed2005

The influence of patient preference on depression treatment in primary care.

BACKGROUND: The chronic illness model encourages consideration of patients' treatment preferences. Moreover, research suggests that matching treatment to preference might affect outcomes for patients with depression. PURPOSE: This investigation explored factors associated with treatment preference matching and the effects of matching on depression treatment outcomes. METHODS: Treatment preferences were assessed among primary care patients with depression participating in a large randomized trial of depression management. Patients were offered antidepressant medication and/or counseling based on preference and several other factors. Depression was assessed at 3 and 9 months. RESULTS: Participants who preferred medication were older, were in worse physical health, and were more likely to already be taking antidepressants. Participants who preferred both medication and counseling evidenced greater agreement with the statement that depression is a medical illness. Overall, 72% of participants were matched with their preferred treatment; matched participants demonstrated more rapid improvement in depression symptomatology than unmatched participants. CONCLUSIONS: Obtaining preferred treatment appears to contribute to improved treatment outcome. Continued attempts to assess for and accommodate treatment preferences might result in better response to depression treatment.

Aged↗

PubMed2004

Income inequality and pregnancy spacing.

We examined the relationship between county-level income inequality and pregnancy spacing in a welfare-recipient cohort in Washington State. We identified 20,028 welfare-recipient women who had at least one birth between July 1, 1992, and December 31, 1999, and followed this cohort from the date of that first in-study birth until the occurrence of a subsequent pregnancy or the end of the study period. Income inequality was measured as the proportion of total county income earned by the wealthiest 10% of households in that county compared to that earned by the poorest 10%. To measure the relationship between income inequality and the time-dependent risk (hazard) of a subsequent pregnancy, we used Cox proportional hazards methods and adjusted for individual- and county-level covariates. Among women aged 25 and younger at the time of the index birth, the hazard ratio (HR) of subsequent pregnancy associated with income inequality was 1.24 (95% CI: 0.85, 1.80), controlling for individual-level (age, marital status, education at index birth; race, parity) and community-level variables. Among women aged 26 or older at the time of the index birth, the adjusted HR was 2.14 (95% CI: 1.09, 4.18). While income inequality is not the only community-level feature that may affect health, among women aged 26 or older at the index birth it appears to be associated with hazard of a subsequent pregnancy, even after controlling for other factors. These results support previous findings that income inequality may impact health, perhaps by influencing health-related behaviors.

Adolescent↗

PubMed2003

Winter respiratory viruses and health care use: a population-based study in the northwest United States.

To quantify health care use among adults during influenza and respiratory syncytial virus (RSV) seasons, we identified a cohort of veterans aged >or=18 years who used Department of Veterans Affairs (VA) facilities in Oregon and Washington states as their source of health care. During 1998-2000, veterans accrued 237,159 person-years of follow-up. Using VA data sources, we measured acute cardiopulmonary hospitalizations and primary care and urgent care visits. Differences between rates of study events when influenza and/or RSV were circulating and event rates when neither virus was circulating were used to calculate winter virus-attributable morbidity. Inpatient and outpatient event rates were consistently higher during winter virus season, compared with non-winter virus season. Annual rates of cardiopulmonary hospitalizations attributable to influenza or RSV infection ranged from 0.8 (95% confidence interval [CI], 0.1-1.5) per 1000 low-risk individuals aged 18-49 years, to 10.6 (95% CI, 7.5-13.6) per 1000 high-risk individuals aged >or=65 years. Each year, circulation of influenza and RSV coincide with predictable increases in medical care use.

Adolescent↗

PubMed2003

Randomized, controlled evaluation of a prototype informed consent process for HIV vaccine efficacy trials.

Procedures must be developed to ensure that valid informed consent is obtained from participants in HIV vaccine efficacy trials. A prototype informed consent process was evaluated among 4,892 persons at high risk for HIV infection in the HIV Network for Prevention Trials Vaccine Preparedness Study (VPS), a prospective cohort study of HIV seroincidence in eight U.S. metropolitan areas. Twenty percent of VPS participants were selected at random to undergo the prototype informed consent process at VPS month 3. Participants' knowledge of 10 key HIV vaccine trial concepts and willingness to participate in HIV vaccine efficacy trials were assessed and compared at baseline and semiannually thereafter for 18 months. Knowledge of HIV vaccine trial concepts was low at baseline. Participation in the prototype process was associated with substantial and sustained increases in knowledge (relative risks for the 10 items, 1.04-2.26), which were of similar magnitude across HIV risk groups, race/ethnicity, and educational levels. It is recommended that the prototype informed consent process be adopted for future HIV vaccine efficacy trials as well as for clinical trials in other research areas.

AIDS Vaccines↗

PubMed2003

A critical evaluation of critical pathways in head and neck cancer.

BACKGROUND: Critical pathways have been purported to decrease resource utilization in the management of head and neck cancer. Prior reports have documented shorter lengths of stay (LOS) for pathway patients than for historical cohorts. OBJECTIVE: To critically evaluate the impact of critical pathways on LOS after laryngectomy. DESIGN: Length-of-stay trends of 2 concurrent observational cohorts of laryngectomy patients (September 1992 to February 1999) were compared, 1 at each of 2 medical centers. One center instituted a critical pathway for laryngectomy patients in February 1997; the other never used such pathways. In addition, we examined the independent impact of the critical pathway at the pathway institution after controlling for date of laryngectomy (which reflected temporal trends) and other confounding variables. RESULTS: Both centers experienced reductions in LOS after February 1997, but there was no statistically significant difference between the reductions (1.9 days at the pathway center vs 1.5 days at the nonpathway center; P>.05). Multivariable linear and linear spline regression models demonstrated that the use of critical pathways at the pathway institution had no statistically significant impact on LOS after controlling for the date of laryngectomy. CONCLUSIONS: Pathway implementation has a limited direct impact on LOS in relatively low-volume procedures such as laryngectomy. Although pathways may influence utilization trends, their impact is likely mediated by the development and educational process that accompanies pathway adoption rather than implementation of the pathway itself. The inclusion of temporal trends and contemporary cohorts provides substantial insight into the effectiveness of critical pathways.

Aged↗

PubMed2003

Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care.

OBJECTIVE: To compare collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provided a treatment plan to the primary care provider, telephoned patients to support adherence to the plan, reviewed treatment results, and suggested modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatry residents practicing in the primary care clinic. DESIGN: Patients were randomly assigned to treatment model by clinic firm. SETTING: VA primary care clinic. PARTICIPANTS: One hundred sixty-eight collaborative care and 186 CL patients who met criteria for major depression and/or dysthymia. MEASUREMENTS: Hopkins Symptom Checklist (SCL-20), Short Form (SF)-36, Sheehan Disability Scale. MAIN RESULTS: Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months there was no significant difference. The intervention increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months. CONCLUSIONS: Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives.

Adult↗

PubMed2003

Cost-effectiveness of collaborative care for depression in a primary care veteran population.

OBJECTIVE: This study examined the incremental cost-effectiveness of a collaborative care intervention for depression compared with consult-liaison care. METHODS: A total of 354 patients in a Department of Veterans Affairs (VA) primary care clinic who met the criteria for major depression or dysthymia were randomly assigned to one of the two care models. Under the collaborative care model, a mental health team provided a treatment plan to primary care providers, telephoned patients to encourage adherence, reviewed treatment results, and suggested modifications. Outcomes were assessed at three and nine months by telephone interviews. Health care use and costs were also assessed. RESULTS: A significantly greater number of collaborative care patients were treated for depression and given prescriptions for antidepressants. The collaborative care patients experienced an average of 14.6 additional depression-free days over the nine months. The mean incremental cost of the intervention per patient was $237 US dollars for depression treatment and $519 US dollars for total outpatient costs. A majority of the additional expenditures were accounted for by the intervention. The incremental cost-effectiveness ratio was $24 US dollars per depression-free day for depression treatment costs and $33 US dollars for total outpatient cost. CONCLUSIONS: Better coordination and communication under collaborative care was associated with a greater number of patients being treated for depression and with moderate increases in days free of depression and in treatment cost. Additional resources are needed for effective collaborative care models for depression treatment in primary care.

Cost-Benefit Analysis↗

PubMed2003

Identifying Depressed Patients With a High Risk of Comorbid Anxiety in Primary Care.

BACKGROUND: Depressive and anxiety disorders are highly prevalent in the primary care setting. There is evidence that patients with depression and comorbid anxiety are more severely impaired than patients with depression alone and require aggressive mental health treatment. The goal of this study was to assess the impact of comorbid anxiety in a primary care population of depressed patients. METHOD: 342 subjects diagnosed with a DSM-IV-defined major depressive episode, dysthymia, or both were asked 2 questions about the presence of comorbid anxiety symptoms (history of panic attacks and/or flashbacks). Patient groups included depression only (N = 119), depression and panic attacks (N = 51), depression and flashbacks (N = 97), and depression and both panic attacks and flashbacks (N = 75). Groups were compared on demographics, mental health histories, and health-related quality-of-life variables. Data were gathered from January 1998 to March 1999. RESULTS: Those patients with depression, panic attacks, and flashback symptoms as compared with those with depression alone were more likely to be younger, unmarried, and female. The group with depression, panic attacks, and flashbacks was also more likely to have more depressive symptoms, more impaired health status, worse disability, and a more complicated and persistent history of mental illness. Regression analysis revealed that the greatest impact on disability, presence of depressive symptoms, and mental health outcomes was associated with panic attacks. CONCLUSION: By asking 2 questions about comorbid anxiety symptoms, primary care providers evaluating depressed patients may be able to identify a group of significantly impaired patients at high risk of anxiety disorders who might benefit from collaboration with or referral to a mental health specialist.

Journal Article↗

PubMed2003

Comparison of 3 Depression Screening Methods and Provider Referral in a Veterans Affairs Primary Care Clinic.

BACKGROUND: Concern about underdiagnosis and undertreatment of depression in primary care has led to support for routine screening. Although multiple screening instruments exist, we are not aware of studies to date that have compared different screening strategies, e.g., how the instrument is administered: by whom and in what setting. This study compared 3 separate screening strategies in terms of patient flow, coverage, patient characteristics, and other factors with the usual care system of provider referral. METHOD: We analyzed existing data from a completed randomized team trial of collaborative care depression treatment in which patients who met DSM-IV criteria for current major depressive disorder, dysthymic disorder, or both were recruited using the usual care system of provider referral (provider) and 3 separate screening strategies: (1) a 2-stage waiting room screening interview (waiting), (2) an in-clinic screen consisting of 2 self-report items embedded in a larger survey (in-clinic), and (3) a 2-stage self-report mail survey (mail). The team trial and analysis were conducted between January 1998 and July 2003. RESULTS: The usual care system of provider referral identified the most depressed patients and had relatively good coverage compared with the 3 screening strategies. Of the 3 screening strategies, the in-clinic strategy had the best coverage, while the mail strategy had the worst coverage. Provider referral patients were younger and had fewer chronic medical illnesses than did other patients. The waiting strategy identified more patients with bipolar affective disorder. CONCLUSION: While different strategies may be optimal for different resource levels and patient characteristics, this study suggests that an in-clinic self-report survey may be the best adjunct to provider referral for efficiently increasing coverage. This study also suggests that different screening strategies may capture different patient populations.

Journal Article↗

PubMed2002

Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder.

We conducted a randomized controlled trial to evaluate whether dialectical behavior therapy (DBT), a treatment that synthesizes behavioral change with radical acceptance strategies, would be more effective for heroin-dependent women with borderline personality disorder (N = 23) than Comprehensive Validation Therapy with 12-Step (CVT + 12S), a manualized approach that provided the major acceptance-based strategies used in DBT in combination with participation in 12-Step programs. In addition to psychosocial treatment, subjects also received concurrent opiate agonist therapy with adequate doses of LAAM (thrice weekly; modal dose 90/90/130 mg). Treatment lasted for 12 months. Drug use outcomes were measured via thrice-weekly urinalyses and self-report. Three major findings emerged. First, results of urinalyses indicated that both treatment conditions were effective in reducing opiate use relative to baseline. At 16 months post-randomization (4 months post-treatment), all participants had a low proportion of opiate-positive urinalyses (27% in DBT; 33% in CVT + 12S). With regard to between-condition differences, participants assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment while those assigned to CVT + 12S significantly increased opiate use during the last 4 months of treatment. Second, CVT + 12S retained all 12 participants for the entire year of treatment, compared to a 64% retention rate in DBT. Third, at both post-treatment and at the 16-month follow-up assessment, subjects in both treatment conditions showed significant overall reductions in level of psychopathology relative to baseline. A noteworthy secondary finding was that DBT participants were significantly more accurate in their self-report of opiate use than were those assigned to CVT + 12S.

Adult↗

PubMed2002

Validation of case-mix measures derived from self-reports of diagnoses and health.

Self-reported chronic diseases and health status are associated with resource use. However, few data exist regarding their ability to predict mortality or hospitalizations. We sought to determine whether self-reported chronic medical conditions and the SF-36 could be used individually or in combination to assess co-morbidity in the outpatient setting. The study was designed as a prospective cohort study. Patients were enrolled in the primary care clinics at seven Veterans Affairs (VA) medical centers participating in the Ambulatory Care Quality Improvement Project (ACQUIP). 10,947 patients, > or = 50 years of age, enrolled in general internal medicine clinics who returned both a baseline health inventory checklist and the baseline SF-36 who were followed for a mean of 722.5 (+/-84.3) days. The primary outcome was all-cause mortality, with a secondary outcome of hospitalization within the VA system. Using a Cox proportional hazards model in a development set of 5,469 patients, a co-morbidity index [Seattle Index of Co-morbidity (SIC)] was constructed using information about age, smoking status and seven of 25 self-reported medical conditions that were associated with increased mortality. In the validation set of 5,478 patients, the SIC was predictive of both mortality and hospitalizations within the VA system. A separate model was constructed in which only age and the PCS and MCS scores of the SF-36 were entered to predict mortality. The SF-36 component scores and the SIC had comparable discriminatory ability (AUC for discrimination of death within 2 y 0.71 for both models). When combined, the SIC and SF-36 together had improved discrimination for mortality (AUC = 0.74, p-value for difference in AUC < 0.005). A new outpatient co-morbidity score developed using self-identified chronic medical conditions on a baseline health inventory checklist was predictive of 2-y mortality and hospitalization within the VA system in general internal medicine patients.

Aged↗

PubMed2002

The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992-1997.

BACKGROUND: The population level frequency of adverse events after antireflux procedures and its relationship to surgical experience has not been well studied. STUDY DESIGN: Two parallel retrospective, population-based cohort studies were conducted using the Washington State discharge database and the United States Health Care Utilization Project (HCUP) database. All adult patients assigned ICD-9 procedure codes for antireflux surgery from 1992 to 1997 were included. The frequency of case fatality, splenectomy, and esophageal injury was measured. In Washington State, the relationship of adverse outcomes to the cumulative number of procedures performed by a given surgeon (case-order) was determined. RESULTS: Nationwide, an estimated 86,411 patients underwent antireflux surgery between 1992 and 1997. Splenectomy was performed in 2.3%, suture of esophageal laceration in 1.1%, and in-hospital death occurred in 0.8%. Adverse events were significantly more likely when procedures at case-order less than or equal to 15 (median) were compared with those at case-order greater than 15. As case-order increased by 1, the risk of death decreased by 1.7% (p = 0.001), and the risk of splenectomy and injury repair decreased by 1.6% (p = 0.001). If performed at case-order less than 15, the odds ofsplenectomy were 2.7 times, esophageal laceration repair 2.3 times, and death 5.6 times greater than the odds of adverse outcomes for procedures performed at later case-orders. CONCLUSIONS: On a national level, morbidity and mortality associated with antireflux surgery performed in the 1 990s was quite low, but was somewhat higher than suggested by case series. Surgical experience with the procedure was linked to better outcomes.

Adult↗